Provider Demographics
NPI:1780312298
Name:FEARLESSLY AUTHENTIC PSYCHOLOGY, LLC
Entity type:Organization
Organization Name:FEARLESSLY AUTHENTIC PSYCHOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:GARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:913-208-4241
Mailing Address - Street 1:332 S CARR ST
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80226-3015
Mailing Address - Country:US
Mailing Address - Phone:913-208-4241
Mailing Address - Fax:
Practice Address - Street 1:777 S WADSWORTH BLVD STE 102
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80226-4300
Practice Address - Country:US
Practice Address - Phone:913-208-4241
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-11
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1992011373OtherNPI